AB0423 STRATEGIES FOR GLUCOCORTICOID TREATMENT IN SYSTEMIC LUPUS ERYTHEMATOSUS FLARES: A REAL-LIFE EXPERIENCE
Authors: L. Scagnellato, M. Maffi, C. Tani, E. Elefante, F. Trentin, F. Ferro, D. Zucchi, C. Stagnaro, L. Carli, M. Mosca
Journal: Annals of the Rheumatic Diseases (2022)

Background Glucocorticoids (GC) are a cornerstone for the treatment of Systemic Lupus Erythematosus (SLE) manifestations but there is still open debate concerning their optimal therapeutic employment. Objectives To describe and compare the GC therapeutic strategies used in a real-life setting for the initial treatment of SLE flares. Methods This study is a retrospective analysis of data from a monocentric cohort of SLE patients who registered a disease flare between 2015 and 2020. Flares were first categorized in “pulse-treated” (PT) and “non pulse-treated” (NPT). PT flares were then divided into “low-dose regimen” (250 mg iv 6MP for 3 consecutive days or less) and “high-dose regimen” (more than 250 mg iv 6MP for 3 days). GC daily and cumulative 6MP doses, rate of remission and relapse were evaluated at 3, 6 and 12 months. Results 101 flares were analyzed (30 PT and 71 NPT). PT flares were more severe in terms of median SLEDAI (PT 16(12-22) vs NPT 8(5-10) p=0,00) and BILAG score index (BILAG A PT 71% vs NPT 30% p=0,001). PT patients received significantly higher GC doses at 1 month (PT median cumulative dose 1372 IQR 1028 – 3076 mg of 6MP vs NPT median 160 IQR 120-288 mg of 6MP, p=0,000), 6 months (PT median cumulative dose 2964 IQR 2294 – 4305 mg of 6MP vs NPT 880 IQR 720 – 1284 mg of 6MP, p=0,000) and 12 months (PT median cumulative dose 3510 IQR 3014-5025 vs NPT median cumulative dose 1571 IQR 1098 – 2122 mg of 6MP, p=0,000). Characteristics of flares that were treated with low-dose (N=19) or high-dose (N=11) pulse regimen are summarized in Table 1. As expected, the “low-dose regimen” subgroup received lower cumulative GC dosage over time. However, no statistically significant differences were found neither in term of disease severity at baseline nor in term of disease activity, remission rates or new flares over time. Table 1. Comparison between low-dose pulse regimen and high-dose pulse regimen in terms of cumulative GC dose and outcome in the first year after a SLE flare Median GC doses (6MP) Low-dose regimenN=19 (63,33%) High-dose regimenN=11 (36,67%) P value Median SLEDAI 16 (12 -20) 18 (8-24) 0,6186 BILAG score (A, B, C) A=14, B=4, C=1 A=10, B=1, C=0 0,488 Cum. dose 1 mo 1350 (1028 – 1534) 1752 (960 – 2356) 0,126 Cum. dose 3 mos 1858 (1604 – 2463) 2784 (2184 – 3240) 0,040 Cum. dose 6 mos 2450 (2218 – 3586) 3456 (2906 – 4380) 0,029 Cumulative doses 12 mos 3150 (2851 - 4448) 4246 (3591 – 5772) 0,011 Remission 3 mos no – (%) 2 (10%) 0 (0%) 0,265 Remission 6 mos no – (%) 8 (42%) 1 (9%) 0,057 Remission 12 mos no – (%) 12 (63%) 5 (45%) 0,346 Median SLEDAI 3 mos 4 (2 – 9) 9 (4 – 12) 0,138 Median SLEDAI 6 mos 3 (0 - 4) 4 (0 – 9) 0,154 Median SLEDAI 12 mos 2 (0 – 5) 2 (0 – 12) 0,363 New flares 6 mos no – (%) 2 (10%) 1 (9%) 0,900 New flares 12 mos no – (%) 2 (10%) 2 (18%) 0,552 GC=glucocorticoids, 6MP=6-methylprednisolone, no=number, Cum.=cumulative, mos=months Conclusion These data suggest that in a real-life setting, pulse GC therapy is preferred over oral administration for severe SLE flares and entails administration of high cumulative doses of GC. However, the experience outlined suggests that the low-dose pulse regimen is as effective in remission induction of severe flares as the high-dose regimen, allowing significant GC sparing. Since the cumulative GC dose is a known strong predictor of organ damage, strategies aimed to minimize the GC dosage should be encouraged. Disclosure of Interests None declared